One of the most well-established independent home care companies in the nation is heading into the new year with a new identity – and a much larger overall business.
Just a few years ago, the Greater Boston-based HouseWorks brought in about $25 million in annual revenues, with nearly all of that coming from private-pay home care services. Now, with 2024 in sight, the provider is approaching $400 million in revenue with a diversified payer mix increasingly weighted toward Medicaid.
The keys to HouseWorks’ astronomical growth in such a short period: the implementation of new core systems, an experienced leadership team and, in InTandem Capital Partners, a market-savvy financial sponsor. The development and implementation of eCaring, a home care technology platform acquired and fine-tuned by HouseWorks, likewise played a major role, according to CEO Mike Trigilio.
“This pivotal evolution marked a transformative moment for the organization,” Trigilio told Home Health Care News.
Trigilio was named CEO of HouseWorks at the beginning of April 2021, taking over for Andrea Cohen, the company’s founder and former top executive. He came to the home care provider from Amedisys Inc. (Nasdaq: AMED), where he ran a personal care division that was largely built on top of Associated Home Care, which Trigilio previously led.
“When I looked at HouseWorks, it reminded me of Associated, and I saw a lot of parallel opportunities to grow it quickly,” Trigilio explained. “I thought if we could put systems in place here at HouseWorks, we could ultimately scale this business, much like we did with Associated.”
HouseWorks’ growth is one of the home care industry’s best-kept secrets of 2023. And it’s a case study for other home care operators, along with investors, hoping to achieve similar results in 2024 beyond.
“I thought if we could put systems in place here at HouseWorks, we could ultimately scale this business, much like we did with Associated.”– HouseWorks CEO Mike Trigilio
Building the foundation
Prior to April 2021, when HouseWorks’ annual revenue clocked in around $25 million, it delivered around 13,500 hours per week of home care services via a team of about 300 caregivers. Most of that business, again, was from private pay.
To take HouseWorks to “the next level” and gear up for an aggressive M&A push, Trigilio and his leadership team knew they needed to reinforce their organization’s foundation. That was done, in part, by implementing improved scheduling and billing software while “solidifying the caregiver experience” by increasing pay rates, offering enhanced benefits and investing in career-development programs.
Integrating eCaring’s data capabilities was another priority. HouseWorks was an early investor in eCaring under the leadership of former-CEO Cohen in 2020. HouseWorks later acquired a majority stake in eCaring in connection with InTandem’s investment in late 2022.
“The technology industry has been pushing out products, but they are finding it difficult to refine and integrate them into supporting seniors in the home,” Cohen told HHCN after the deal was announced. “It’s hard for them to find partners to experiment with. We felt that in order to be successful moving forward, we have to integrate technology to enhance the experience of our customers.”
While all of that was taking place, Trigilio and the HouseWorks executive team were simultaneously working on an M&A playbook that took the lessons learned from a series of smaller acquisitions the company completed over the years and outlined areas for improvement.
The playbook also pulled from what Trigilio had learned from his time at Amedisys, from due-diligence best practices to how buyers should handle the first 30, 60 and 90 days post-acquisition.
“I learned quite a bit while I was working there, especially the focus on systems and repeatable structure,” Trigilio said.
Even with the long list of to-dos, a lot of that foundational work happened over a three-week period.
“We put together a 21-day sprint document that analyzed all the things that we needed to update within the infrastructure of the company,” Trigilio said. “From there, we addressed where the biggest holes were, what we could handle internally versus externally, where we needed to go as far as bringing in additional help.”
The fruits of that labor began to come that fall.
In October 2021, HouseWorks acquired Atlantic Homelife Senior Care, which has locations in New Hampshire and Maine.
Less than a month later, it announced a deal to buy the Eastern Massachusetts-concentrated Connected Home Care, propelling HouseWorks into the Medicaid space in a significant way for the first time. By strategically expanding into Medicaid, HouseWorks was able to diversify its revenue while adding a greater degree of stability to its business, Trigilio said.
“[Private pay] is a great business, but it also has some ups and downs,” he noted. “It’s more bumpy, and your revenue per client can really move your business around a bit. It’s much harder to predict.”
In early 2022, HouseWorks doubled down on Medicaid by buying Greater Boston Home Health Care Services. After executing that transaction, HouseWorks became several times larger than what it was just six months prior.
Its hours of care delivered per week jumped to 25,000, with its caregiver workforce climbing to 900. Its annual revenues rose to about $45 million.
Up until that point, HouseWorks had been backed by RAB Ventures. As Trigilio set his sights on 2023, however, he believed a new capital partner was critical to keep HouseWorks on the upswing.
“We just needed a larger partner,” he said. “So the board and myself, we met mid-22, and we decided to run a process that would enable us to continue to scale.”
Taking the next step
That’s when InTandem Capital Partners entered the picture.
New York-based InTandem Capital Partners is a private equity firm that invests in small- to mid-sized health care services companies. Its portfolio includes senior primary care group Cano Health, fertility services leader Ivy Fertility and ambulatory infusion leader Vivo Infusion. Most relevant to HouseWorks, though, are its in-home care investments Providence Care and Pediatric Home Service.
Compared to other possible partners during the sales process, HouseWorks and InTandem had clear alignment on a growth roadmap and Medicaid expansion, Trigilio said.
As a cherry on top, Trigilio had an established rapport with InTandem Senior Partner Brad Coppens.
“We’ve known Mike for several years,” Coppens told HHCN. “Mike and his team were a key part of our conviction in starting our investment program with HouseWorks, which at the time of our original investment was a modest-sized company.”
InTandem officially invested in HouseWorks in December 2022. Almost immediately after that investment came, the pair sent a letter of intent out to Amedisys for the Baton Rouge, Louisiana-based provider’s $60 million personal care division – Associated Home Care, effectively – that Trigilio once headed.
The transaction netted more than a dozen care centers in multiple states.
“It’s been a whole lot of fun getting to see all those people again,” Trigilio said. “The business is in great shape.”
Any integration process is challenging – let alone a handful happening at the same time. But HouseWorks and InTandem weren’t done adding.
In May 2023, HouseWorks bought Care and Help Home Care in the Philadelphia area. A couple months later, HouseWorks landed Druk Home Care – another Pennsylvania provider.
Most recently – on Tuesday, in fact, – HouseWorks announced a definitive agreement to partner with Elite Home Health Care, a home-based care provider in New York. Elite – which cracked the top of Fortune Magazine’s “Best Workplaces in Aging Services” list – delivers care to close to 4,000 clients, primarily in the New York City metro area, plus the Rochester, Buffalo and Syracuse regions.
It’s important to note that all this dealmaking came at a time when home care-related M&A activity was somewhat depressed, at least compared to the pandemic-fueled run on home-based care assets in late 2020 and throughout 2021. More broadly, many PE firms have pulled back on health care investments due to macroeconomic challenges, including inflation and the rising cost of capital.
“Quite naturally, as the economic and capital markets picture became more complicated, it became more difficult to complete acquisitions,” Coppens said. “Fortunately, given our experience in this sector, we were very well-versed with regard to the provider landscape in these three major markets of New York, Massachusetts and Pennsylvania. We were able to evaluate and execute these acquisitions relatively easily.”
On the horizon
The fast-paced M&A strategy has transformed HouseWorks into the largest home care provider in Massachusetts, and one of the eight-largest providers in both New York and Pennsylvania. What’s more, along with scale, the dealmaking wave added new services to HouseWorks’ offerings.
Elite Home Health Care brought adult day services and a four-location caregiver-training school, for example. Care and Help included meal-delivery services, while Associated Home Care had a laundry business.
Being able to offer multiple aging-in-place services is a selling point with payers, Trigilio said.
“Instead of having three different providers providing three different things, it’s much cleaner to have one single organization doing that,” he said.
As HouseWorks closes out 2023, its revenue figures are “right around $400 million,” according to Trigilio and Coppens. And its team of caregivers – currently more than 12,000 in number – is delivering about 250,000 hours of care per week.
To continue hitting its ambitious growth goals, HouseWorks will likely target three to five additional transactions in 2024, Trigilio said. The company will keep its focus on the broad Northeast and mid-Atlantic markets, valuing density more than geographic coverage.
“We’re certainly looking for additional opportunities in New York and Pennsylvania,” Trigilio said. “And some parts of New Hampshire and Maine.”
Completing the integration of all of its recent purchases will, of course, remain a focus as well, the CEO said. The same is true for further investing in caregiver-support initiatives and beefing up the HouseWorks leadership team.
HouseWorks named Aveanna Healthcare (Nasdaq: AVAH) veteran Nick Sansone as its new COO on Monday. Since Trigilio took over as CEO, the company has also brought on a new CFO and CTO, while promoting internally across multiple leadership promotions.
“We’re really focused on caregiver retention, really focused on listening to our workforce and making sure that they’re getting what they need to provide the right level of care in the home,” Trigilio said. “Beyond that, our focus is on working with our payer partners and understanding the level of data they want.”